Single-port, traditional laparoscopy outcomes comparable

March 1, 2009

Recent reports have suggested that single-incision laparoscopic surgery (SILS) is technically feasible.

Shanghai, China-The introduction of laparoscopy in the early 1990s ushered in a new era in the surgical treatment of human diseases. Evolution of minimally invasive techniques has furthered an impetus in the surgical community to reduce the invasiveness of laparoscopic surgery. To achieve this goal, surgeons have proposed limiting the number of abdominal incisions or eliminating them completely.

Recent reports from a number of institutions have suggested that single-incision laparoscopic surgery (SILS), also known as single-port surgery, is technically feasible. In one study, researchers from the University of Texas Southwestern Medical Center in Dallas, led by Jeffrey Cadeddu, MD, found that SILS and conventional laparoscopic nephrectomy yielded similar perioperative and short-term convalescence outcomes.

The study, presented at the World Congress of Endourology & SWL, involved a case-control comparison of 11 SILS nephrectomy procedures and 22 conventional laparoscopic nephrectomies, all performed by a single surgeon between September 2004 and April 2008. SILS procedures were performed by inserting three adjacent 5-mm trocars through a single 2.5-cm peri-umibilical incision. Articulating laparoscopic graspers and a Maryland dissector, coupled with a 45°, 5-mm camera were used for SILS nephrectomy. The control group was matched in a 2:1 ratio to SILS cases with respect to patient age, surgical indication (ie, benign vs. malignant process) and tumor size for cases of malignancy.

There was no significant difference in operative time (median, 122 vs. 125 minutes), decline in postoperative hemoglobin levels (14% vs. 16%) or narcotic analgesic use (8 vs. 15 morphine equivalents). Importantly, the complication rate (0% for both groups) and length of hospital stay were comparable (49 vs. 53 hours) between the SILS and standard laparoscopic groups, reported first author Jay Raman, MD, a former UT Southwestern fellow now at the Milton S. Hershey Medical Center, Hershey, PA.

"While the above findings may have been expected, a notable observation was the reduced recorded blood loss for the SILS group (20 mL vs. 100 mL; p=.001)." Dr. Raman said.

The UT Southwestern group concluded that in experienced hands, SILS nephrectomy is feasible, with perioperative outcomes, complication rates, and short-term convalescence comparable to those seen in an age-matched conventional laparoscopic nephrectomy cohort. These outcomes may be attributable to all cases being performed by an experienced surgeon who had previously completed multiple SILS nephrectomy cases in a porcine model and who has overcome the learning curve of the unique articulating instrumentation.

The future of SILS/LESS

Minimally invasive surgery has become the standard treatment for many disease processes and procedures. One of the newest innovations in this field has been the development of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). While these new techniques are in their infancy, a great deal of confusion has arisen regarding the nomenclature and terminology associated with these procedures. SILS is an acronym trademarked by instrument manufacturer Covidien (North Haven, CT) for its multiple-instrument access port device used in single-incision surgery. At a recent consortium meeting, all single-port procedures, which include the single-port, multiple-port, and single multi-port platform used via a single incision/location on the abdomen, flank or back, have been collectively termed LESS (J Endourol 2008; 22:2575-81).

Future work is needed to better define the ideal operative procedures for single-site surgery, which will continue to evolve as novel articulating instrumentation, imaging devices, and robotic platforms are integrated into surgical practice. An additional important feature for SILS development will be providing adequate surgical training and education for surgical residents in order to ensure that future urologic surgeons will be able to offer this surgical option to patients when appropriate.

The UT Southwestern authors emphasized that single-site surgery is still in its infancy. Indeed, studies are necessary to better define the oncologic and functional outcomes with this novel surgical approach. Furthermore, prospective comparisons are needed to ensure that preservation of modern-day surgical outcomes while defining the objective benefits of single-site surgery.